Abstract
In our recent correspondence, we highlighted the complexity of defining productivity benchmarks for Advanced Practice Providers (APPs) in academic palliative medicine. 1 Across academic medical centers, there is now a broader movement toward establishing relative value unit (RVU) targets for APPs, following national trends in benchmarking and compensation practices. While such targets provide structure, their implications in academic medicine remain nuanced.
The rationale for RVU targets is grounded in transparency, alignment, and sustainability. RVU benchmarks allow institutions to demonstrate the measurable contributions of APPs, align APP productivity with physician standards, and provide data for resource allocation and workforce planning. Standardized targets can also help protect APP roles by offering administrators clear evidence of return on investment in times of financial scrutiny.2–4
Concerns about RVU targets focus on potential unintended consequences. Academic APPs contribute substantially to non-billable but essential activities, including interdisciplinary team processes, patient and family communication, education, quality improvement, and research. A narrow emphasis on RVU generation risks undervaluing these contributions, shifting effort toward billable encounters and away from the broader academic mission. 2 Additionally, APP and physician roles may inadvertently overlap, creating competition for billable activities rather than reinforcing the team-based care model that academic centers seek to preserve. In palliative care (PC), where visits are complex and time-intensive, this tension is particularly pronounced as reflected by the overall lower RVU productivity compared to other disciplines. 3
As one example, the University of Florida Department of Medicine (DOM) recently developed a PC APP RVU benchmark by converting encounter-based targets into RVUs. Internal data demonstrated that PC APPs averaged 2,200 RVUs annually, closely aligned with national academic benchmarks. This is consistent with findings from an informal Duke survey, in which APPs across academic programs averaged approximately 77% of physician RVU targets. 1 By establishing an APP benchmark in PC without attaching incentives or penalties, the intent is to promote accountability and transparency in workload expectations while recognizing the broader value of non-billable academic contributions. This approach also supports career development and advancement opportunities for APPs, which can enhance institutional recognition of their contributions, foster job satisfaction and retention, and reduce costly turnover.
More recently, the DOM introduced additional approaches to standardize APP productivity across divisions. If an APP does not achieve their target, the difference between actual and expected RVUs is converted into “negative RVUs,” which are redistributed across compensation plan-eligible faculty. Divisions with hospital outpatient departments may alternatively elect to remove APP RVUs—both target and actual—from productivity data and instead apply national “physician-only” benchmarks. While this method aligns with national standards, it may also disincentivize physicians from supporting APP clinical activity, as collaborative and supervisory work is no longer reflected in their measurable productivity. Although these approaches currently apply to other DOM divisions, they have not been applied to outpatient PC at our institution yet.
As institutions move toward RVU targets, it remains critical to balance financial accountability with recognition of the multifaceted roles APPs play in academic medicine. Models that integrate RVU expectations while preserving space for education, research, and team-based care may provide a path forward. It is increasingly likely that APPs will be subject to formal productivity targets accompanied by associated incentives (e.g., bonuses) and consequences (e.g., salary adjustments and negative performance evaluations), similar to those already applied to physicians. Ultimately, success will depend on whether RVU benchmarks can be implemented in ways that sustain collaboration and uphold the academic mission.3,4